Management of Uterocutaneous Fistula
Surgical excision of the fistulous tract with uterine repair using absorbable suture material is the definitive treatment for uterocutaneous fistula, preceded by infection control and diagnostic imaging to delineate the tract. 1
Initial Assessment and Diagnosis
Confirm the diagnosis with MRI, which provides the highest sensitivity and specificity for defining fistula anatomy and associated complications 2, 3. Hysteroscopy is valuable for visualizing the uterine opening of the fistula tract and assessing the endometrial cavity 3, 4.
The methylene blue test can verify the diagnosis by introducing dye through a transcervically placed uterine catheter and observing flow through the external opening 5.
Immediate Management: Control Infection First
Administer IV antibiotics immediately if active infection, cellulitis, or sepsis is present 6. This is critical before any definitive intervention, as operating in the presence of active infection leads to failure and potential sepsis 6.
- Drain any associated abscesses before attempting closure 2, 6
- Complete a full course of parenteral antibiotics targeting identified organisms 6
- Never attempt primary closure or definitive surgery in the presence of active infection—this will result in failure and worsening sepsis 6, 7
Definitive Treatment: Surgical Approach
Complete surgical excision of the fistulous tract with uterine repair is required for definitive management 1, 4, 5. The evidence consistently demonstrates that conservative surgical treatment is successful when properly executed.
Surgical Technique:
- Perform complete excision of the fistulous tract, including any enclosing omentum or scar tissue 1, 5
- Repair the uterus using slowly-absorbable suture material—non-absorbable sutures are a reported underlying cause of fistula formation 1
- The procedure can be performed via laparotomy or combined laparoscopy/laparotomy depending on complexity 3, 4
Timing of Surgery:
- Delay definitive surgery until infection is completely controlled and the patient is optimized 6
- Allow adequate time for resolution of inflammatory changes before attempting repair 7
Conservative Medical Therapy Option
For patients desiring future fertility, consider combined medical and conservative surgical treatment 3. One case report demonstrated success with:
- GnRH agonist therapy (leuprolide acetate) administered monthly for 6 months before surgery 3
- This approach combined with conservative surgical excision preserved the uterus and allowed for normal uterine cavity restoration 3
However, this represents limited evidence from case reports, and the standard approach remains complete surgical excision.
Critical Pitfalls to Avoid
- Do not perform intrauterine procedures (hysteroscopy, curettage) in patients with recent cesarean section and infectious perioperative status without careful evaluation—this can precipitate or worsen fistula formation 8
- Do not use non-absorbable suture material for uterine repair—this is a documented cause of fistula development 1
- Do not delay diagnosis—symptoms can be nonspecific (cyclical bleeding from scar, pelvic pain, persistent discharge), leading to medical wandering and delayed care 1, 8
- Do not confuse with endometriosis—cyclical bleeding from a cesarean scar can mimic endometriosis, but the presence of a tract on imaging distinguishes uterocutaneous fistula 1
Underlying Causes to Address
Uterocutaneous fistula typically follows cesarean section and results from 1, 8:
- Non-absorbable suture material in the uterus 1
- Infection and necrosis 1
- Chorioamnionitis or septic abortion 8, 5
- Foreign bodies 1